Diagnostic value of tachycardia features and pacing maneuvers during

paroxysmal supraventricular tachycardia

Bradley P. Knight, Matthew Ebinger, Hakan Oral, Michael H. Kim, Christian
Sticherling, Frank Pelosi, Gregory F. Michaud, S. Adam Strickberger, and Fred
Morady
J. Am. Coll. Cardiol. 2000;36;574-582

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Journal of the American College of Cardiology Vol. 36, No. 2, 2000
© 2000 by the American College of Cardiology ISSN 0735-1097/00/$20.00
Published by Elsevier Science Inc. PII S0735-1097(00)00770-1

Diagnostic Value of Tachycardia

Features and Pacing Maneuvers
During Paroxysmal Supraventricular Tachycardia
Bradley P. Knight, MD, FACC, Matthew Ebinger, DO, Hakan Oral, MD, Michael H. Kim, MD,
Christian Sticherling, MD, Frank Pelosi, MD, Gregory F. Michaud, MD,
S. Adam Strickberger, MD, FACC, Fred Morady, MD, FACC
Ann Arbor, Michigan
OBJECTIVES The purpose of this prospective study was to quantitate the diagnostic value of several
tachycardia features and pacing maneuvers in patients with paroxysmal supraventricular
tachycardia (PSVT) in the electrophysiology laboratory.
BACKGROUND No study has prospectively compared the value of multiple diagnostic tools in a large group
of patients with PSVT.
METHODS One hundred ninety-six consecutive patients who had 200 inducible sustained PSVTs during
an electrophysiology procedure were included. The diagnostic values of four baseline
electrophysiologic parameters, nine tachycardia features and five diagnostic pacing maneuvers
were quantified.
RESULTS The only tachycardia characteristic that was diagnostic of atrioventricular (AV) nodal reentry
was a septal ventriculoatrial (VA) time of ⬍70 ms, and no pacing maneuver was diagnostic
for AV nodal reentry. An increase in the VA interval with the development of a bundle
branch block was the only tachycardia characteristic that was diagnostic for orthodromic
tachycardia, but it occurred in only 7% of all tachycardias. An atrial-atrial-ventricular response
upon cessation of ventricular overdrive pacing was diagnostic of atrial tachycardia, and this
maneuver could be applied to 78% of all tachycardias. Burst ventricular pacing excluded atrial
tachycardia when the tachycardia terminated without depolarization of the atrium, but the
result could be obtained only in 27% of patients.
CONCLUSIONS This prospective study quantitates the diagnostic value of multiple observations and pacing
maneuvers that are commonly used during PSVT in the electrophysiology laboratory. The
findings demonstrate that diagnostic techniques rarely provide a diagnosis when used
individually. Therefore, careful observations and multiple pacing maneuvers are often
required for an accurate diagnosis during PSVT. The results of this study provide a useful
reference with which new diagnostic techniques can be compared. (J Am Coll Cardiol 2000;
36:574 – 82) © 2000 by the American College of Cardiology

Several tachycardia features and diagnostic pacing maneu-
vers have been proposed to differentiate the various forms of
paroxysmal supraventricular tachycardia (PSVT) in the
electrophysiology laboratory (1–11). The usefulness of
some, but not all, of these diagnostic techniques has been
studied individually (5–10). However, no study has prospec-
tively compared the value of multiple diagnostic tools. The
purpose of this prospective study was to quantitate the
diagnostic usefulness of several tachycardia features and
pacing maneuvers commonly used in the electrophysiology
laboratory in a large group of consecutive patients with
PSVT.
METHODS
Study design. Patients who had inducible PSVT during an
electrophysiology procedure were included in this study.
Baseline electrophysiologic parameters and tachycardia fea-
tures were characterized. After tachycardia was induced,
From the Department of Internal Medicine, Division of Cardiology, University of
Michigan Health System, Ann Arbor, Michigan.
Manuscript received September 7, 1999; revised manuscript received February 16,
2000, accepted March 30, 2000.
prospectively defined diagnostic pacing maneuvers were
performed and the response to each maneuver was recorded.
After the tachycardia diagnosis was established, the preva-
lence, sensitivity, specificity and predictive values of each
diagnostic technique were calculated.
Characteristics of subjects. The study population con-
sisted of 196 consecutive patients with inducible sustained
PSVT. Their mean age was 46 ⫾ 16 years (range 14 to 85
years), and 67% were women. A majority of patients (85%)
had no evidence of structural heart disease. The remaining
patients had coronary artery disease (n ⫽ 10), hypertension
(n ⫽ 10), nonischemic dilated cardiomyopathy (n ⫽ 4),
aortic valve disease (n ⫽ 3), hypertrophic cardiomyopathy
(n ⫽ 1), previous atrial septal defect repair (n ⫽ 1) or
previous ventricular septal defect repair (n ⫽ 1).
Electrophysiologic procedure. Electrophysiology proce-
dures were performed using standard techniques (10). An-
tiarrhythmic drug therapy was discontinued for at least five
half-lives. In the first 100 patients, recordings of four
electrocardiographic (ECG) leads and three intracardiac
electrograms were made on paper at a speed of 100 mm/s
using a Mingograph 7 recorder (Siemens-Elema, Solna,
Sweden). The intracardiac electrograms were filtered at 40

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JACC Vol. 36, No. 2, 2000
August 2000:574–82
Abbreviations and Acronyms
AH ⫽ atrial His bundle
AV ⫽ atrioventricular
ECG ⫽ electrocardiogram, electrocardiographic
PSVT ⫽ paroxysmal supraventricular tachycardia
VA ⫽ ventriculoatrial
and 500 Hz. The recordings also were digitized and stored
on optical disks (Quinton Electrophysiology, Seattle,
Washington). In the remaining 96 patients, digital record-
ings of 12 ECG leads and five intracardiac electrograms
were displayed and stored on optical disk using the EP
Workmate recording system (EP Medical Systems, Mt.
Arlington, New Jersey). The intracardiac electrograms were
filtered at 30 and 500 Hz and displayed with amplifier
settings of ⫾0.5 to ⫾1.0 mV.
Overdrive atrial and ventricular pacing and premature
extrastimuli were used to induce supraventricular tachycar-
dia. Intravenous isoproterenol was administered if tachycar-
dia was not inducible or was nonsustained at baseline (12).
Diagnostic tachycardia features. Four baseline observa-
tions and nine tachycardia features were prospectively cho-
sen for evaluation and are summarized in Table 1. Dual
atrioventricular (AV) nodal physiology was defined as an
increase of ⱖ50 ms in the A2H2 interval with atrial
extrastimuli decremented in 10-ms steps. Para-Hisian pac-
ing was performed by overdrive pacing at the site of the
largest His bundle recording with various stimulation in-
tensities to achieve simultaneous ventricular and His bundle
capture as well as ventricular capture alone. The response
was considered extranodal when the retrograde atrial acti-
vation timing during His bundle capture was the same as
during ventricular capture without His bundle capture (8).
Diagnostic pacing maneuvers. Five diagnostic pacing ma-
neuvers were prospectively chosen for evaluation in this
study (Table 2). Each maneuver was intended to elicit a
response that was either diagnostic or provided supportive
evidence for a tachycardia mechanism. After tachycardia
was induced, as many pacing maneuvers were performed as
possible depending on the ability to reproducibly induce the
tachycardia. Maneuvers were performed in an order that was
felt to be helpful clinically, but not all tachycardias were
reproducibly inducible. Therefore, not all maneuvers were
performed during some tachycardias. The response to each
maneuver was recorded. The term “entrainment” was used
in this study to refer to acceleration of the atrial and
ventricular electrograms to the pacing cycle length during
overdrive pacing from the atrium or ventricle, with resump-
tion of the original cycle length upon cessation of pacing.
The first pacing maneuver was to overdrive pace the high
right atrium transiently during tachycardia at a cycle length
just below the tachycardia cycle length. If the tachycardia
terminated, tachycardia was reinduced and the maneuver
was repeated. If the tachycardia continued upon cessation of
pacing, the ventriculoatrial (VA) interval of the return cycle
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Knight et al. 575
Diagnostic Value of Maneuvers During PSVT
Table 1. Baseline Observations and Tachycardia Features
Prospectively Selected for Evaluation
Baseline Observations and Tachycardia Features
Baseline Observations
1. Ventricular preexcitation during sinus rhythm
2. Dual AV nodal physiology
3. VA block cycle length ⬎600 ms at baseline
4. Extranodal response to Para-Hisian pacing during sinus rhythm
Tachycardia Features
1. Induction dependent on a critical AH interval
2. Isoproterenol required to sustain tachycardia
3. Tachycardia cycle length ⱖ500 ms
4. Septal VA interval ⬎70 ms
5. Eccentric atrial activation
6. Spontaneous AV block during tachycardia
7. Spontaneous termination with AV block
8. Development of bundle branch block
9. Effect of bundle branch block on VA conduction time
AH ⫽ atrial His bundle; AV ⫽ atrioventricular; VA ⫽ ventriculoatrial.
was categorized as fixed if the interval was within 10 ms of
the VA interval during tachycardia. Otherwise, the interval
was considered variable. A fixed VA interval would be
expected to occur in AV nodal reentry or orthodromic
reciprocating tachycardia because the timing of atrial acti-
vation is dependent on ventricular activation (Fig. 1). A
variable interval suggests that the tachycardia is atrial (5).
The second maneuver was to overdrive-pace the right
atrium repeatedly during tachycardia at the longest cycle
length that resulted in AV block. The last atrial His bundle
(AH) interval upon cessation of pacing was evaluated. If
termination of the tachycardia was associated with an AH
interval that was relatively short compared with the AH
intervals that resulted in continuation of tachycardia, tachy-
cardia termination was considered to be dependent on the
last AH interval (5). Termination of atrial tachycardia
would not be expected to be dependent on the AH interval.
The third pacing maneuver was to overdrive-pace the
right ventricle transiently during tachycardia at a cycle
length just shorter than the tachycardia cycle length. Among
patients in whom overdrive pacing did not result in accel-
eration of the atrial rate to the pacing rate, the reason was
either because the VA block cycle length during tachycardia
was greater than the tachycardia cycle length or because the
tachycardia always terminated during ventricular pacing. If
ventricular pacing terminated the tachycardia, the tachycar-
dia was reinduced and the maneuver was repeated. When
entrainment of the atrium during the tachycardia with
ventricular pacing was possible, the atrial activation se-
quence was categorized as either the same or different
compared with the activation sequence during tachycardia.
A different activation sequence would be consistent with an
atrial tachycardia or a bystander accessory pathway. Also,
when entrainment was possible, the electrogram sequence
immediately after the last paced ventricular complex was
categorized as “atrial-ventricular” (A-V) or “atrial-atrial-
ventricular” (A-A-V). An A-A-V response is consistent
with an atrial tachycardia and an A-V response is consistent
576 Knight et al. JACC Vol. 36, No. 2, 2000
Diagnostic Value of Maneuvers During PSVT August 2000:574–82

Table 2. Five Prospectively Identified Diagnostic Pacing Maneuvers and Questions Asked
Pacing Maneuver Questions Asked
1. Pace the atrium during SVT at a CL 10–40 ms ⬍ SVT CL ● Is VA interval with return beat the same as during SVT?
2. Pace the atrium during SVT at AV Block CL ● Is SVT termination dependent on last AH interval?
3. Pace the ventricle during SVT at a CL 10–40 ms ⬍ SVT CL ● Can the atrial rate be accelerated to the ventricular pacing rate?
● If the atrial rate cannot be accelerated to the ventricular pacing rate, is it
because the SVT always terminates or because the VA block CL during
SVT ⬎ SVT CL?
● If the atrial rate can be accelerated to ventricular pacing rate, is the
response upon cessation of pacing “A-A-V” or “A-V”?
● If the atrial rate can be accelerated to ventricular pacing rate, is the atrial
activation the same as during SVT?
4. Pace ventricle during SVT at a CL 200–250 ms for 3–6 beats ● Can SVT be terminated by burst ventricular pacing without depolarization
of the atrium?
5. Scan diastole with a premature ventricular stimulus ● Can SVT be terminated with a ventricular extrastimulus during His-
bundle refractoriness?
● Can SVT be terminated with a ventricular extrastimulus without affecting
the atrium?
A-A-V ⫽ atrial-atrial-ventricular; A-V ⫽ atrial-ventricular; AV ⫽ atrioventricular; CL ⫽ cycle length; SVT ⫽ supraventricular tachycardia; VA ⫽ ventriculoatrial.

with AV nodal reentry or orthodromic AV reentrant tachy-
cardia (10).
The fourth pacing maneuver was to burst-pace the right
ventricle for three to six beats during tachycardia at a cycle
length of 200 ms to 250 ms. This was repeated until the
maneuver resulted in tachycardia termination or until at
least three attempts had been made. If the ventricle was
dissociated from the tachycardia and termination did not
occur, orthodromic reentrant tachycardia was excluded. If
termination occurred during ventricular pacing, it was de-
termined whether or not the atrium had been depolarized.
Tachycardia termination without depolarization of the
atrium excludes atrial tachycardia (Fig. 2).
The fifth pacing maneuver was to scan diastole with a
ventricular extrastimulus from the right ventricular apex
during tachycardia. The responses that were evaluated
included whether or not tachycardia termination occurred,
whether or not the His bundle was refractory when termi-
nation occurred, and whether or not the atrium was depo-
larized when termination occurred. Atrial depolarization or
tachycardia termination with a ventricular extrastimulus
delivered during His bundle refractoriness during tachycar-
dia is consistent with the presence of an accessory AV
connection.
Diagnosis of tachycardia mechanism. Tachycardia diag-
noses were made based on standard criteria (1–11) and the
results of ablation. A diagnosis of each tachycardia was
made with certainty. An atrial activation sequence that was
not compatible with retrograde conduction through the AV
junction excluded AV nodal reentry. Atrial tachycardia was

Figure 1. Example of the first diagnostic pacing maneuver. Shown are surface electrograms I, II, III, V1, and intracardiac recordings from the high right
atrium (HRA), His-bundle electrogram (HBE), and right ventricular apex (RVA). The tachycardia is entrained with atrial pacing. The VA interval of the
return beat is the same as the VA interval of the tachycardia. This observation, referred to as “VA linking,” would not be expected during atrial tachycardia
because atrial activation is not dependent on ventricular activation. S ⫽ stimulus.

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JACC Vol. 36, No. 2, 2000
August 2000:574–82
Figure 2. Example of the fourth diagnostic pacing maneuver. The format is the same as Figure 1. A burst of ventricular pacing is delivered during
tachycardia. The tachycardia terminates without depolarization of the atrium. The last beat of the tachycardia is denoted with an asterisk. This observation
excludes atrial tachycardia. S ⫽ stimulus.
excluded if ventricular pacing or a ventricular extrastimulus
terminated the tachycardia without depolarizing the atrium,
or when the VA conduction interval changed with the
development of bundle-branch block aberration. Findings
considered diagnostic for orthodromic reciprocating tachy-
cardia included an increase in the VA conduction interval
with the development of bundle-branch block. Ortho-
dromic reciprocating tachycardia was excluded if tachycardia
persisted during AV block. Atrioventricular nodal reentry
was considered typical if the septal VA interval was ⱕ70 ms
and atypical if the interval was ⬎70 ms.
Radiofrequency ablation of each tachycardia was at-
tempted, except for eight of the 25 atrial tachycardias (three
patients had a left atrial tachycardia and were rescheduled
for a transeptal procedure, and five patients had an atrial
tachycardia that could not be mapped, because the tachy-
cardia was not reproducibly sustainable). Ablation was
successful in 98% of AV nodal reentrant tachycardias, 95%
of orthodromic reciprocating tachycardia, and 82% of atrial
tachycardias.
Data analysis. Continuous variables are expressed as
mean ⫾ SD and were compared using the Student t-test
and analysis of variance. Nominal variables were compared
by chi-square analysis. Logistic regression was used to
determine whether the predictive value of left bundle-
branch aberration for orthodromic tachycardia was indepen-
dent of the tachycardia rate. A p value of ⬍0.05 was
considered significant.
The sensitivity, specificity, positive predictive value and
negative predictive values of each observation and maneuver
were determined. Predictive values of each finding depend
on the overall distribution of AV nodal reentry, ortho-
dromic reciprocating and atrial tachycardias. However, in
this study, not all five pacing maneuvers were performed
during each tachycardia. If the distribution of tachycardias
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Knight et al. 577
Diagnostic Value of Maneuvers During PSVT
tested with one of the maneuvers differed from the overall
distribution of tachycardias, then the predictive values of
that maneuver would be inaccurate. For example, if only 1%
of the tachycardias tested with the fifth maneuver (scanning
diastole with a ventricular extrastimulus) were orthodromic
reciprocating tachycardias, then no finding would have a
high positive predictive value for orthodromic reciprocating
tachycardia. Therefore, the predictive values were calculated
as though each maneuver had been performed in every
patient.
RESULTS
Tachycardia diagnoses. The tachycardia diagnoses, mean
tachycardia cycle lengths and mean septal VA intervals are
summarized in Table 3.
Value of baseline observations and tachycardia features.
The prevalence, sensitivity, specificity, positive predictive
value and negative predictive values of each baseline obser-
vation and tachycardia feature are summarized in Table 4.
The only characteristic that was diagnostic of AV nodal
reentry was a septal VA time of ⱕ70 ms. There were no
atrial tachycardias in this study with a septal VA time of
ⱕ70 ms. Characteristics that were strongly predictive of AV
nodal reentry were dual AV nodal physiology, induction
dependent on a critical AH interval, and concentric activa-
tion. Eccentric atrial activation excluded AV nodal reentry
and occurred in 31% of tachycardias. An increase in the VA
interval ⬎20 ms with a bundle-branch block aberration also
excluded AV nodal reentry and occurred in 7% of tachycar-
dias.
An increase in the VA interval with the development of
a bundle-branch block was the only tachycardia feature that
was diagnostic for orthodromic tachycardia. Ventricular
preexcitation had positive predictive value of 86%. Other
578 Knight et al.
Diagnostic Value of Maneuvers During PSVT
Table 3. Supraventricular Tachycardia Characteristics
Overall
Number (%) 113 (57%)
Cycle Length (ms) 333 ⫾ 71
Septal VA Interval (ms) 55 ⫾ 47
*VA interval ⱕ70 ms (“slow-fast”).
**VA interval ⬎70 ms (“slow-slow” or “fast-slow”).
AT ⫽ atrial tachycardia; AVNRT ⫽ atrioventricular nodal reentry; ORT ⫽ orthodromic reciprocating tachycardia; VA ⫽
ventriculoatrial.
characteristics that had a high positive predictive value but
were not diagnostic for orthodromic tachycardia were an
extranodal response with para-Hisian pacing and the devel-
opment of a left bundle-branch block with tachycardia. A
septal VA interval of ⱕ70 ms and spontaneous AV block
during tachycardia excluded orthodromic reciprocating
tachycardia. Absence of VA conduction at baseline was rare
among patients with orthodromic reciprocating tachycardia
but did not completely exclude the diagnosis.
No tachycardia feature had a significant positive predic-
tive value for atrial tachycardia. Although more patients
with atrial tachycardia developed AV block during tachy-
cardia compared with patients with AV nodal reentry, when
AV block occurred during tachycardia, the tachycardia was
more likely to be AV nodal reentry because atrial tachycar-
dia was much less common than AV nodal reentry (13).
Spontaneous termination of tachycardia with AV block
excluded atrial tachycardia but occurred in only 28% of
tachycardias. There were no cases of atrial tachycardia in
this study with a septal VA interval that was ⱕ70 ms or that
demonstrated an extranodal response to para-Hisian pacing.
Inductions that appeared dependent on a critical AH
interval did not entirely exclude atrial tachycardia.
Value of diagnostic pacing maneuvers during PSVT. No
diagnostic pacing maneuver confirmed a diagnosis of AV
nodal reentry, but some maneuvers were able to exclude the
diagnosis (Table 5). When the termination appeared de-
pendent on a short AH interval during atrial pacing, there
was still a 30% likelihood of orthodromic reciprocating
tachycardia. Findings from maneuvers that excluded AV
nodal reentry included a different atrial activation during
entrainment from the ventricle as during tachycardia, an
A-A-V response upon cessation of entrainment from the
ventricle, and termination of the tachycardia with a ventric-
ular extrastimulus when the His bundle was refractory.
Pacing maneuvers were occasionally able to completely
rule in or rule out orthodromic reentrant tachycardia, but
these findings were uncommon. Termination of the tachy-
cardia with a ventricular extrastimulus when the His bundle
was refractory without affecting atrial depolarization was
diagnostic of orthodromic reciprocating tachycardia, but it
occurred only in 10% of tachycardias. When the tachycardia
could be entrained with ventricular pacing, a different atrial
activation sequence during entrainment from the ventricle
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JACC Vol. 36, No. 2, 2000
August 2000:574–82
Tachycardia Diagnosis
AVNRT
Typical* Atypical** ORT AT p Value
102 (51%) 11 (6%) 62 (31%) 25 (13%) NA
329 ⫾ 71 363 ⫾ 63 338 ⫾ 56 361 ⫾ 66 0.17
43 ⫾ 28 162 ⫾ 55 157 ⫾ 58 214 ⫾ 70 ⬍0.001
than during tachycardia and an A-A-V response upon
cessation of entrainment from the ventricle excluded a
diagnosis of orthodromic reciprocating tachycardia. The
inability to entrain the atrium during the tachycardia with
ventricular pacing because the VA block cycle length was
greater than the tachycardia cycle length, and a dissociation
of the ventricle from the tachycardia with pacing also
excluded orthodromic reciprocating tachycardia.
An A-A-V response upon cessation of ventricular pacing
and an atrial activation sequence during entrainment from
the ventricle that was different than during tachycardia were
diagnostic of atrial tachycardia. The inability to entrain the
atrium during the tachycardia with ventricular pacing
because the VA block cycle length was greater than the
tachycardia cycle length had an 80% positive predictive
value for atrial tachycardia. Any effect with a ventricular
extrastimulus when the His bundle was refractory, including
tachycardia termination and/or atrial preexcitation, ex-
cluded atrial tachycardia. Atrial tachycardias required iso-
proterenol for induction more often than AV nodal reentry
and orthodromic reciprocating tachycardia, but the predic-
tive value was poor.
Value of combinations of observations and maneuvers
during PSVT. Because multiple clues are used to deter-
mine a diagnosis in the electrophysiology laboratory, the
value of combinations of observations and maneuvers was
determined. Although no simple algorithm could be devised
that would quickly lead to a diagnosis for each tachycardia,
a valuable and efficient approach was identified. The com-
bination of two tachycardia observations (the septal VA
interval and the retrograde atrial activation sequence) and
one pacing maneuver (the response immediately after en-
trainment from the ventricle) provided a diagnosis in 65% of
the tachycardias. If the septal VA interval is ⱕ70 ms and the
response after entrainment from the ventricle is A-V, then
the diagnosis is AV nodal reentry (found in 41% of
tachycardias). If the septal VA interval is ⬎70 ms, atrial
activation is eccentric, and the response after entrainment
from the ventricle is A-V, then the diagnosis is orthodromic
tachycardia (found in 19% of tachycardias). If the response
after entrainment from the ventricle is A-A-V, then the
tachycardia is atrial (found in 5% of tachycardias). Other
combinations of the results of these two observations and
one pacing maneuver were not diagnostic, but they excluded
JACC Vol. 36, No. 2, 2000 Knight et al. 579
August 2000:574–82 Diagnostic Value of Maneuvers During PSVT

either AV nodal reentry, orthodromic tachycardia or atrial

AH ⫽ atrial His bundle; AT ⫽ atrial tachycardia; AVNRT ⫽ atrioventricular nodal reentry; BBB ⫽ bundle branch block; CL ⫽ cycle length; LBBB ⫽ left bundle branch block; NPV ⫽ negative predictive value; PPV ⫽ positive predictive
86
82
93
85

71
91
87
100
93
91
82
82
87
92
AT
ORT tachycardia in 79% of the remaining tachycardias.
NPV (%)

78
36
66
80

42
58
69
100
88
65
70
71
81
57
DISCUSSION
Main findings. The main findings of this study are that
ANVRT

several observations made during sinus rhythm, tachycardia

46
82
41
36

87
56
44
0
19
44
48
42
36
51
features and diagnostic pacing maneuvers can be used to
differentiate the various forms of PSVT in the electrophys-
iology laboratory. However, it is uncommon that a tachy-
AT

3
8
55
0

1
17
0
24
24
40
0
11
4
0
cardia mechanism can be determined on the basis of an
individual finding; tachycardia diagnoses are often one of
ORT

86
6
5
83

8
18
17
59
76
0
34
35
92
100
exclusion, and some pacing maneuvers cannot be applied in
PPV (%)

a significant number of tachycardias. Because atrial tachy-

cardia is much less common than AV nodal reentry and
ANVRT

orthodromic reciprocating tachycardia, many features that

10
86
41
17

91
65
83
17
0
60
66
54
4
0
are more common during atrial tachycardia have a low
positive predictive value for atrial tachycardia. The findings
of this study support the use of careful observations and
AT

83
42
84
80

36
62
97
54
74
93
67
67
87
80

several pacing maneuvers during PSVT in the electrophys-

value; ORT ⫽ orthodromic reciprocating tachycardia; RBBB ⫽ right bundle branch block; SVT ⫽ supraventricular tachycardia; VA ⫽ ventriculoatrial.

iology laboratory.
Specificity (%)
ORT

Predictive value of baseline measurements. The finding

97
24
84
96

26
51
96
69
89
85
73
69
99
100

of dual AV nodal physiology in a patient with PSVT makes

AV nodal reentry very likely (positive predictive value, 86%).
ANVRT

However, 6% of patients with dual AV node physiology had

69
83
84
67

88
68
99
0
30
91
78
66
73
69

orthodromic reciprocating tachycardia, and 8% had an atrial

tachycardia. In addition, evidence of an accessory pathway
Table 4. Prevalence and Diagnostic Value of Baseline Observations and Tachycardia Features

did not guarantee that orthodromic reciprocating tachycar-

4
36
50
0

4
57
0
100
61
33
0
30
4
0
AT

dia was the tachycardia mechanism. Ten percent of patients

with preexcitation had AV nodal reentry. Therefore, it must
Sensitivity (%)

be remembered that dual AV nodal pathways and accessory

ORT

41
10
2
47

16
23
2
100
74
0
31
36
36
35

pathways can be incidental findings.

The diagnostic value of para-Hisian pacing during sinus
rhythm may be underestimated in this study. The technique
ANVRT

3
86
8
5

90
47
4
16
0
11
33
31
1
0

is best used to identify a septal pathway, but it was evaluated

in this study in patients with accessory pathways in all
locations. The positive predictive value of an extranodal
response was 100% for orthodromic reciprocating tachycar-
Prevalence

dia among the 31 tachycardias with a VA interval between

(%)

15
55
11
18

55
39
3
53
31
10
28
32
12
7

80 and 120. This reinforces the benefit of diagnostic tools

used in combination.
The absence of VA conduction at baseline did not
Baseline Observations and Tachycardia Features

● Induction dependent on a critical AH interval

entirely exclude the presence of an accessory pathway. There

● Isoproterenol required to sustain tachycardia
● VA block cycle length ⬎600 ms at baseline

● Increase in VA interval ⬎20 ms with BBB

● Extranodal response to para-Hisian pacing

● Spontaneous AV block during tachycardia

● Preexcitation present during sinus rhythm

was still a 5% chance that the tachycardia was orthodromic

● Spontaneous termination with AV block

reciprocating tachycardia when the VA block cycle length

● Tachycardia cycle length ⱖ500 ms

was ⬎600 ms at baseline. The reason is that conduction

through accessory pathways sometimes is catecholamine-
● Septal VA interval ⬎70 ms
● Dual AV nodal physiology

dependent (14).
● Eccentric atrial activation

● Development of RBBB
● Development of LBBB

Usefulness of measurements made during and at the

initiation of tachycardia. The induction of typical AV
Baseline Observations

Tachycardia Features

nodal reentry is dependent on antegrade block in the fast

pathway and sufficient antegrade delay in the slow pathway
to allow retrograde fast pathway conduction. In this study a
critical AH interval was required in 96% of tachycardias of
typical AV nodal reentry. However, induction of an atrial
tachycardia occasionally occurs with atrial pacing only at a

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 Knight et al. 580

Table 5. Diagnostic Value of Pacing Maneuvers during Supraventricular Tachycardia

Percent of
Tachycardias Percent Percent Sensitivity (%) Specificity (%) PPV (%) NPV (%)
Maneuver Able to Frequency
Pacing Maneuver/Result Attempted Entrain of Result AVNRT ORT AT AVNRT ORT AT AVNRT ORT AT AVNRT ORT AT
Pace the atrium at 10–40 ms ⬍SVT 89 87
CL to entrain ventricle
Fixed VA interval 87 97 98 5 27 18 3 64 35 1 87 96 17
Diagnostic Value of Maneuvers During PSVT

Pace the atrium at the AV block CL 69 NA

Termination dependent on AH 80 96 76 8 44 20 11 69 30 1 88 65 47
Pace the ventricle at 10–40 ms 97 78
⬍SVT CL to entrain atrium
Atrial activation same as SVT 92 100 100 0 20 13 0 64 36 0 100 100 0
A-V response after pacing 94 100 100 0 14 89 0 63 37 0 100 100 0
VA block CL ⬎SVT CL 7 3 0 48 86 89 98 20 0 80 41 66 93
Ventricular pacing CL 200–250 ms 91 NA
Termination w/o affecting atrium 27 27 37 0 74 78 69 57 43 0 44 73 83
Ventricle dissociated from SVT 16 11 0 16 95 88 93 75 0 25 45 66 89
Ventricular extrastimulus during 80 NA
diastole
SVT terminates, atrium not 3 0 8 0 94 100 97 0 100 0 42 71 87
affected, His bundle refractory
SVT terminates, atrium affected, 10 0 27 0 80 100 92 0 100 0 38 75 86
His bundle refractory
SVT does not terminate, atrium 12 0 34 0 76 100 88 0 100 0 37 77 86
affected, His bundle refractory

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AT ⫽ atrial tachycardia; AVNRT ⫽ atrioventricular nodal reentry; AV ⫽ atrioventricular; CL ⫽ cycle length; NA ⫽ not applicable; NPV ⫽ negative predictive value; PPV ⫽ positive predictive value; ORT ⫽ orthodromic reciprocating
tachycardia; SVT ⫽ supraventricular tachycardia; VA ⫽ ventriculoatrial.
JACC Vol. 36, No. 2, 2000
August 2000:574–82
JACC Vol. 36, No. 2, 2000
August 2000:574–82
cycle length that results in a long AH interval, and it may
appear as if a critical AH is required. In addition, the
induction of orthodromic reciprocating tachycardia requires
a critical delay in the AV interval to allow retrograde recovery
of the accessory pathway, and it may appear as though a critical
AH interval is required. Therefore, whether or not the induc-
tion of tachycardia is dependent on a critical AH interval is not
in itself sufficient to make a diagnosis.
Previous studies have found that orthodromic reciprocat-
ing tachycardia tends to be faster than AV nodal reentry (1).
However, the mean rates of orthodromic reciprocating
tachycardia and AV nodal reentry were not different in this
study. By contrast, atrial tachycardias tended to have a
slower mean rate than AV nodal-dependent tachycardias.
However, the slowest tachycardias were AV nodal reentry and
orthodromic reciprocating tachycardia. There were no atrial
tachycardias in this study with a cycle length greater than
500 ms. Therefore, although relatively slow supraventricular
tachycardias are uncommon, they are usually not atrial.
One of the first tachycardia features used to differentiate
different types of PSVT was the VA interval (6). A value of
60 to 70 ms has been consistently found to discriminate
orthodromic reciprocating tachycardia from AV nodal re-
entry (7). The results of this study confirm the value of the
VA interval. No cases of orthodromic reciprocating tachy-
cardia had a septal VA interval of ⬍70 ms. In addition,
there were no cases of atrial tachycardia with a short VA
interval. Atrial tachycardia with a short VA interval is
theoretically possible, but appears to be very uncommon.
Diagnostic value of spontaneous AV or bundle-branch
block. The spontaneous development of AV or bundle-
branch block is very useful diagnostically but uncommon.
Although persistence of tachycardia during AV block ex-
cludes orthodromic reciprocating tachycardia, it occurs in
only 10% of tachycardias. Furthermore, it is not helpful in
discriminating AV nodal reentry from atrial tachycardia. In
fact, the positive predictive value of persistent tachycardia in
the face of AV block was higher for AV nodal reentry than
for atrial tachycardia. Spontaneous termination with AV
block excludes atrial tachycardia but occurs in only 28% of
tachycardias.
A significant change in the VA interval with the devel-
opment of bundle-branch block has long been known to be
diagnostic of orthodromic reciprocating tachycardia and local-
izes the pathway to the same side as the block (9). Results of
this study demonstrate that an increase in the VA interval of
⬎20 ms is diagnostic of orthodromic reciprocating tachycardia,
but it occurs in only 7% of patients with PSVT.
Interestingly, the mere development of left bundle-
branch aberration with tachycardia is strongly predictive of
orthodromic reciprocating tachycardia (92% positive predic-
tive value) and is predictive of orthodromic reciprocating
tachycardia independent of the tachycardia rate. Patients
who developed a left bundle-branch block had a shorter
tachycardia cycle length compared with those who did not,
although the difference did not reach statistical significance
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Knight et al. 581
Diagnostic Value of Maneuvers During PSVT
(317 ⫾ 54 vs. 340 ⫾ 68 ms; p ⫽ 0.12). However, patients
with orthodromic reciprocating tachycardia were 77 times
more likely to develop a left bundle-branch block aberration
than if they had AV nodal reentry, regardless of the
tachycardia cycle length. Left bundle-branch block aberra-
tion occurred in 36% of patients with orthodromic recipro-
cating tachycardia, 1% with AV nodal reentry and 4% with
atrial tachycardia (p ⬍ 0.001). Right bundle-branch block
occurred in approximately one third of patients with each
form of PSVT.
Two reasons have been proposed to explain why pro-
longed aberration occurs less commonly during AV nodal
reentry than orthodromic reciprocating tachycardia (1).
First, the induction of AV nodal reentry requires significant
AV nodal delay, which makes the H1H2 interval longer and
makes aberration unlikely. Second, left bundle-branch block
facilitates induction of orthodromic reciprocating tachycar-
dia when a left-sided accessory pathway is present. In this
study, 19 of the 24 cases of orthodromic reciprocating
tachycardia that developed left bundle-branch aberration
had a left-sided accessory pathway.
Diagnostic value of pacing maneuvers. Atrial pacing
maneuvers were most helpful by providing evidence against
atrial tachycardia. Neither of the two atrial-based pacing
maneuvers evaluated in this study were able to exclude atrial
tachycardia completely. A VA interval with the first return
beat after atrial pacing with 1:1 conduction that is the same
as the VA interval during the tachycardia suggests that atrial
activation is linked to ventricular activation and was ex-
pected to exclude atrial tachycardia. However, coincidental
events can rarely result in apparent “VA linking” during
atrial tachycardia. In addition, a VA interval with the first
return beat that differs from the VA interval during tachy-
cardia was not expected to be seen with AV nodal reentry,
but it occurred in 3% of tachycardias. A recent study has also
demonstrated variation in the VA interval at the induction
of AV nodal reentry (15). Atrial pacing maneuvers were not
helpful in differentiating AV nodal reentry from ortho-
dromic reciprocating tachycardia.
The findings of this study confirm the value of
ventricular-based pacing maneuvers during a narrow com-
plex tachycardia. An A-V response upon cessation of pacing
completely excluded the possibility of atrial tachycardia, and
this maneuver could be applied to 78% of all tachycardias. In
the remainder of tachycardias, when VA block occurred
during attempts to entrain the tachycardia, there was an
80% likelihood that the tachycardia was atrial. The advan-
tages of this maneuver have recently been described and
include speed and persistence of the tachycardia after the
maneuver is completed (10).
Burst ventricular pacing to terminate the tachycardia
without depolarizing the atrium is commonly proposed as a
helpful initial diagnostic maneuver. The maneuver can
clearly exclude atrial tachycardia, but this result was ob-
tained in only 27% of patients because the tachycardia
usually terminates when the atrium is depolarized. The
582 Knight et al.
Diagnostic Value of Maneuvers During PSVT
maneuver appears to be worthwhile when entrainment from
the ventricle provides diagnostic findings. Twenty-five of
the tachycardias could not be entrained from the ventricle,
because the tachycardia would always terminate. When
burst ventricular pacing was performed during these tachy-
cardias, a useful finding was obtained in 62% (burst ven-
tricular pacing resulted in dissociation of the ventricle in
31% and resulted in termination without depolarizing the
atrium in 31% of the tachycardias).
Previous studies. A previous study systematically evaluated
the diagnostic value of overdrive atrial and ventricular
pacing in 53 patients with PSVT (5). This study was able to
quantify the usefulness of diagnostic techniques identified in
the previous study in a larger group of patients and to
prospectively compare overdrive pacing to other diagnostic
tools.
Study limitations. One limitation of this study is that
some rare types of tachycardia were not represented in the
study. Therefore, some findings that resulted in a 100%
positive predictive value for a particular tachycardia mech-
anism may not be completely diagnostic. For example,
termination of a tachycardia with a ventricular extrastimulus
when the His bundle is refractory without depolarizing the
atrium is not diagnostic of orthodromic reciprocating tachy-
cardia using an accessory AV connection, because it is
possible that the tachycardia is using a concealed nodofas-
cicular bypass tract.
Another limitation is that the predictive values may not
apply to all electrophysiology laboratories. Our case mix was
representative of the expected prevalence of AV nodal
reentry, orthodromic reciprocating tachycardia and atrial
tachycardia. However, the predictive values would differ in a
laboratory that has a different referral pattern (for example,
a laboratory that specializes in atrial tachycardia).
A third limitation is that some diagnostic maneuvers that
have been described, such as the administration of adeno-
sine (16) and carotid sinus pressure (17), were not tested in
this study. However, the number of maneuvers performed
had to be limited to allow completion during a clinically
indicated electrophysiologic procedure.
The predictive value of some of the tachycardia observa-
tions may not apply to PSVTs that occur spontaneously. For
example, the predictive value of left bundle-branch aberra-
tion may be poor when the tachycardia is not induced by
pacing.
Clinical implications. Successful ablation of PSVT is de-
pendent on an accurate diagnosis of the tachycardia mech-
anism. This prospective study quantitates the diagnostic
value of multiple observations and pacing maneuvers that
are commonly used during PSVT in the electrophysiology
laboratory. The findings demonstrate that diagnostic tech-
niques rarely provide a diagnosis when used individually. A
combination of two tachycardia observations (the septal VA
interval and the retrograde atrial activation sequence) and
one pacing maneuver (the response immediately after en-
trainment from the ventricle) provided a diagnosis in 65% of
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JACC Vol. 36, No. 2, 2000
August 2000:574–82
the tachycardias and excluded a tachycardia mechanism in
an additional 27% of tachycardias. Therefore, careful obser-
vations and multiple pacing maneuvers are often required
for an accurate diagnosis during PSVT. The results of this
study provide a useful reference with which new diagnostic
techniques can be compared.
Reprint requests and correspondence: Dr. Bradley P. Knight,
University of Michigan Health System, 1500 East Medical Center
Drive/B1F245, Ann Arbor, Michigan 48109-0022. E-mail:
bpk@umich.edu.
REFERENCES
1. Josephson M. Supraventricular tachycardia. In: Josephson M, editor.
Clinical Cardiac Electrophysiology. Philadelphia: Malvern, Lea &
Febiger, 1993:181–274.
2. Jackman WM, Nakagawa H, Heidbuchel H, Beckman K, McClelland
J, Lazzara R. Three forms of atrioventricular nodal (junctional)
reentrant tachycardia: differential diagnosis, electrophysiological char-
acteristics, and implications for anatomy of the reentrant circuit. In:
Zipes DP, Jalife J, editors. Cardiac Electrophysiology: From Cell to
Bedside. Philadelphia: Saunders, 1995:620 –37.
3. Leitch J, Klein GJ, Yee R, Murdock C. Invasive electrophysiologic
evaluation of patients with supraventricular tachycardia. Cardiol Clin
1990;8:465–77.
4. Josephson ME, Wellens HJJ. Differential diagnosis of paroxysmal
supraventricular tachycardia. Cardiol Clin 1990;8:411– 42.
5. Kadish AH, Morady F. The response of paroxysmal supraventricular
tachycardia to overdrive atrial and ventricular pacing: can it help
determine the tachycardia mechanism? J Cardiovasc Electrophysiol
1993;4:239 –52.
6. Benditt D, Prichett E, Smith W, Gallagher JJ. Ventriculoatrial
intervals: diagnostic use in paroxysmal supraventricular tachycardia.
Ann Intern Med 1976;91:161– 6.
7. Ross DL, Uther JB. Diagnosis of concealed accessory pathways in
supraventricular tachycardia. Pacing Clin Electrophysiol 1984;7:1069 –
85.
8. Hirao K, Otomo K, Wang X, et al. Para-Hisian pacing: a new method
for differentiating retrograde conduction over an accessory AV path-
way from conduction over the AV node. Circulation 1996;94:1027–35.
9. Kerr CR, Gallagher JJ, German LD. Changes in ventriculoatrial
intervals with bundle branch block aberration during reciprocating
tachycardia in patients with accessory atrioventricular pathways. Cir-
culation 1982;66:196 –201.
10. Knight BP, Zivin A, Souza J, et al. A technique for the rapid diagnosis
of atrial tachycardia in the electrophysiology laboratory. J Am Coll
Cardiol 1999;33:775– 81.
11. Iesaka Y, Takahashi A, Goya M, et al. Adenosine-sensitive atrial
reentrant tachycardia originating from the atrioventricular nodal tran-
sitional area. J Cardiovasc Electrophysiol 1997;8:854 – 64.
12. Strickberger SA, Daoud EG, Niebauer MJ, Hasse C, Man KC,
Morady F. The mechanisms responsible for lack of reproducible
induction of atrioventricular nodal reentrant tachycardia. J Cardiovasc
Electrophysiol 1996;6:494 –502.
13. Man KC, Brinkman K, Bogun F, et al. 2:1 Atrioventricular block
during atrioventricular nodal reentrant tachycardia. J Am Coll Cardiol
1996;28:1770 – 4.
14. Yamamoto T, Yeh SJ, Lin FC, Wu DL. Effects of isoproterenol on
accessory pathway conduction in intermittent or concealed Wolff-
Parkinson-White syndrome. Am J Cardiol 1990;65:1438 – 42.
15. Tnaiguchi Y, Yeh SJ, Wen MS, Wang CC, Lin FC, Wu C. Variation
of P-QRS relation during atrioventricular node reentry tachycardia.
J Am Coll Cardiol 1999;33:376 – 84.
16. Glatter KA, Cheng J, Dorostkar P, et al. Electrophysiologic effects of
adenosine in patients with supraventricular tachycardia. Circulation
1999;99:1034 – 40.
17. Josephson ME, Seides SE, Batsford WB, Caracta AR, Damato AN,
Kastor JA. The effects of carotid sinus pressure in reentrant paroxysmal
supraventricular tachycardia. Am Heart J 1974;88:694 –7.
 Diagnostic value of tachycardia features and pacing maneuvers during
paroxysmal supraventricular tachycardia
Bradley P. Knight, Matthew Ebinger, Hakan Oral, Michael H. Kim, Christian
Sticherling, Frank Pelosi, Gregory F. Michaud, S. Adam Strickberger, and Fred
Morady
J. Am. Coll. Cardiol. 2000;36;574-582
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